Judymara Lauzi Gozzani

Medida da ansiedade e da depressão em pacientes no pré-operatório. Estudo comparativo

JUSTIFICATIVA Y OBJETIVOS: Los pacientes que seran sometidos a un procedimiento quirurgico tuvieron ansiedad. La ansiedad y la depresion son los disturbios mas asociados a las enfermedades fisicas. En la Escala Hospitalaria de Ansiedad y Depresion (HADS) no figuran items que podrian estar presentes en enfermedades fisicas y en la ansiedad y en la depresion. El objetivo de este estudio fue medir la frecuencia y el nivel de la ansiedad y de la depresion en pacientes en el preoperatorio y en un grupo control. METODO: Setenta y nueve pacientes internados en el Departamento de Cirugia de la Santa Casa de Sao Paulo y 56 acompanantes respondieron a un cuestionario de datos socio demograficos y la HADS. RESULTADOS: La evaluacion de los sintomas mostro que 35 (44,3%) pacientes y 36 (64,3%) acompanantes fueron considerados con ansiedad (teste exacto de Fisher - p = 0,03) y 21 (26,6%) pacientes y 23 (41,1%) acompanantes fueron considerados con depresion (p = 0,09). En relacion al impacto de las variables socio demograficas sobre la medida de la ansiedad y de la depresion, se observo apenas que los pacientes sin empleo presentaron un nivel mas elevado de ansiedad. CONCLUSIONES: Este estudio confirmo la posibilidad del uso de la escala HADS de ansiedad y depresion en pacientes quirurgicos internados. Tambien nos mostro que la evaluacion de la ansiedad en el periodo preoperatorio debe ser realizada, independientemente de que el paciente presente o no enfermedad clinica y/o quirurgica grave, pues la frecuencia de pacientes con ansiedad es relevante y ellos merecen algun tipo de cuidado diferenciado, como minimo el uso de medicacion ansiolitica antes de la intervencion quirurgica. Fueron encontrados niveles significativamente mayores de ansiedad entre los acompanantes de los pacientes. Esas personas, evaluadas sin que existiese un concomitante problema clinico, posiblemente demostraron estar expuestas a un nivel ostensible de estres, lo que conllevo a un estado de ansiedad mayor que el que tendrian los pacientes que serian sometidos a procedimiento quirurgico.BACKGROUND AND OBJECTIVES Patients scheduled for surgeries experience anxiety. Anxiety and depression are the disorders most commonly associated with organic diseases. The Hospital Anxiety and Depression Scale (HADS) does not include items that could be present in organic diseases and in anxiety and depression. The objective of this study was to measure the frequency and the level of anxiety and depression in preoperative patients and in a control group. METHODS Seventy-nine patients admitted to the Surgical Department of Santa Casa de São Paulo and 56 caretakers answered a questionnaire on socio-demographic data and the HADS. RESULTS The evaluation of the symptoms showed that 35 (44.3%) patients and 36 (64.3%) caretakers had anxiety (Fisher Exact test - p = 0.03) and 21 (26.6%) patients and 23 (41.1%) caretakers had depression (p = 0.09). Regarding the impact of the socio-demographic data on the measurement of anxiety and depression, it was only observed that patients that were unemployed had higher anxiety levels. CONCLUSIONS This study confirmed that the HADS could be used in hospitalized surgical patients. It also showed that patients should be evaluated preoperatively for anxiety and depression, regardless of the presence of severe clinical and/or surgical disorders, because the frequency of patients with anxiety is relevant and they deserve a differentiated approach - at least the administration of tranquilizers before surgery. Caretakers presented significantly higher levels of anxiety. Those people, evaluated in the absence of concomitant clinical problems, probably demonstrated to be exposed to a considerable level of stress, resulting in a higher anxiety state than the patients scheduled for surgeries.JUSTIFICATIVA E OBJETIVOS: Os pacientes que vao ser submetidos a um procedimento cirurgico experimentam ansiedade. A ansiedade e a depressao sao os disturbios mais associados as doencas fisicas. Na Escala Hospitalar de Ansiedade e Depressao (HADS) nao figuram itens que poderiam estar presentes em doencas fisicas e na ansiedade e na depressao. O objetivo deste estudo foi medir a frequencia e o nivel da ansiedade e da depressao em pacientes no pre-operatorio e em um grupo-controle. METODO: Setenta e nove pacientes internados no Departamento de Cirurgia da Santa Casa de Sao Paulo e 56 acompanhantes responderam a um questionario de dados sociodemograficos e a HADS. RESULTADOS: A avaliacao dos sintomas mostrou que 35 (44,3%) pacientes e 36 (64,3%) acompanhantes foram considerados com ansiedade (teste Exato de Fisher - p = 0,03) e 21 (26,6%) pacientes e 23 (41,1%) acompanhantes foram considerados com depressao (p = 0,09). Com relacao ao impacto das variaveis sociodemograficas sobre a medida da ansiedade e da depressao, foi observado apenas que os pacientes desempregados apresentaram nivel mais elevado de ansiedade. CONCLUSOES: Este estudo confirmou a possibilidade do uso da escala HADS de ansiedade e depressao em pacientes cirurgicos internados. Ele mostrou tambem que a avaliacao da ansiedade no periodo pre-operatorio deve ser realizada, independentemente de o paciente apresentar ou nao doenca clinica e/ou cirurgica grave, pois a frequencia de pacientes com ansiedade e relevante e estes merecem algum tipo de cuidado diferenciado no minimo o uso de medicacao ansiolitica antes da intervencao cirurgica. Foram encontrados niveis muito maiores de ansiedade entre os acompanhantes dos pacientes. Essas pessoas, avaliadas sem que houvesse um concomitante problema clinico, possivelmente demonstraram estar expostas a um consideravel nivel de estresse, o que resultou em estado ansioso maior do que os pacientes que seriam submetidos a procedimento cirurgico.

Effect of dexamethasone on prevention of postoperative nausea, vomiting and pain after caesarean section: a randomised, placebo-controlled, double-blind trial.

Context Spinal morphine is a common form of postoperative analgesia after caesarean section, but it is associated with postoperative nausea and vomiting. Objective To evaluate the hypothesis that dexamethasone reduces nausea and vomiting in patients undergoing caesarean section under spinal anaesthesia with morphine. Design Interventional, randomised, double-blinded, placebo-controlled study to evaluate a preoperative single dose of dexamethasone. Setting Patients from a tertiary hospital in the city of Sao Paulo, Sao Paulo, Brazil observed from 1 January through 30 June 2008. Patients or other participants Seventy full-term pregnant patients (American Society of Anesthesiologists 1 or 2) were studied. Patients were randomly allocated into two groups determined by a computerised table. Exclusion criteria were contraindication to regional anaesthesia, allergy to dexamethasone, opioids or local anaesthetics, hypertension or diabetes originated during pregnancy and use of any antiemetic drug received before surgery. Spinal anaesthesia consisted of hyperbaric bupivacaine and morphine. Intervention Patients received either dexamethasone 10 mg in 100 ml of isotonic saline, intravenously or 100 ml of isotonic saline (placebo) prior to surgery. Main outcome Incidence of postoperative nausea and vomiting in the first 24 h were rated and recorded. Pain scores at rest and on movement were evaluated using a visual analogue scale. Results During the first 24 hours, nausea occured in 12/35 (34.4%) patients receiving dexamethasone and in 32/35 (91.4%) receiving placebo (P < 0.001). During the same time period, vomiting occured in 12/35 (34.4%) patients receiving dexamethasone and in 29/35 (82.9%) receiving placebo (P < 0.001). Pain at rest and pain on movement was lower in patients who received dexamethasone at some time points during the study period. Conclusion Dexamethasone reduced the cumulative incidence of nausea and vomiting after caesarean section under spinal anaesthesia with morphine and lowered pain scores on the first postoperative day.

Dor neuropática: aspectos neuroquímicos

BACKGROUND AND OBJECTIVES: Neuropathic pain is caused by damage or inflammation of the nervous system. It is a complex syndrome and its biological mechanisms, involving inflammatory and immunologic theories, are not clear. The objective of this review was to describe the main biologic factors associated with neuropathic pain, making a logical association between hypotheses suggested in the literature. CONTENTS: The main neuromediators, ion channels, and cells, including cells in the nervous system involved in neuronal excitation are described, and the possible activation sequence or interaction among those agents in the neoplastic change secondary to nerve damage are emphasized. CONCLUSIONS: It was possible to conclude that the advances on the knowledge of the pathophysiology of neuropathic pain can determine new pharmacologic approaches for this syndrome.

Ansiedade no período pré-operatório de cirurgias de mama: estudo comparativo entre pacientes com suspeita de câncer e a serem submetidas a procedimentos cirúrgicos estéticos

BACKGROUND AND OBJECTIVES Evaluation of anxiety is not part of the routine pre-anesthetic evaluation (APA). Therefore, special situations in which patients might present altered mood will go unnoticed by the anesthesiologist. The objective of this study was to compare, at the moment of the outpatient basis APA, the risk factors, severity, and prevalence of anxiety in patients with suspected breast cancer and those undergoing cosmetic surgery of the breast. METHODS After approval by the Ethics Committee, 114 patients, ASA I or II, 14 years or older, were studied at the APA clinic; they were divided in two groups: GMAMA - patients with suspected breast cancer; GPLAST - patients undergoing cosmetic surgery. After signing the informed consent, patients answered the anxiety evaluation test (STAI - State-Trait Anxiety Inventory) before the preanesthetic evaluation. The following parameters were analyzed: socio-demographic data; prior experience with surgical procedures; number and percentage of patients with low, moderate, or high anxiety (STAI I and II); and median of the STAI I and II scores. RESULTS Both groups were homogenous regarding the socio-demographic data and prior experience with surgical procedures. There was a significant difference in the levels and prevalence of anxiety-state (STAI I). No risk factors for anxiety-state and anxiety-trait were identified. CONCLUSIONS Patients with suspected breast cancer scheduled for nodulectomy or removal of breast tissue for diagnosis, had higher levels and prevalence of anxiety-state than patients undergoing mammaplasty; the levels and prevalence of anxiety-trait were similar in both groups; no risk factors for anxiety-state and anxiety-trait were identified.JUSTIFICATIVA Y OBJETIVOS: La evaluacion de la ansiedad no forma parte de la rutina de la evaluacion preanestesica (APA), lo que hace que situaciones especiales en que el estado emocional de los pacientes pueda estar alterado pasen desapercibidas por el anestesiologo. Este estudio quiso comparar al momento de la APA ambulatorial, factores de riesgo, intensidad y prevalencia de ansiedad en pacientes con sospecha de cancer de mama a ser sometidas a procedimientos quirurgicos esteticos de mama. METODO: Despues de la aprobacion por el Comite de Etica, fueron estudiadas en el ambulatorio de APA, 114 pacientes, ASA I o II, edad > 14 anos, divididas en los grupos: GMAMA - pacientes con sospecha de cancer de mama; GPLAST - pacientes a ser sometidas a cirugia plastica estetica. Despues del consentimiento aclarado, las pacientes respondieron al la prueba de evaluacion de ansiedad (IDATE - Inventario de Ansiedad Trazo-Estado) antes de la evaluacion preanestesica. Se analizaron: datos sociodemograficos; experiencia con procedimientos quirurgicos anteriores; numero y porcentaje de pacientes con ansiedad baja, moderada y alta (IDATE I y II); promedio de los puntajes de las escalas IDATE I y II. RESULTADOS: Los grupos fueron homogeneos en relacion a los datos sociodemograficos y experiencia con procedimientos quirurgicos anteriores. Se observo diferencia significativa de los niveles y prevalencia de ansiedad-estado (IDATE I). No fueron identificados factores de riesgo para ansiedad-estado y ansiedad-trazo. CONCLUSIONES: Las pacientes con sospecha de cancer de mama a ser sometidas a la retirada de nodulo o tejido mamario para diagnostico presentaron niveles y prevalencia de ansiedad-estado alta mayores que las pacientes a ser sometidas a mamoplastias; los niveles y la prevalencia de ansiedad-trazo fueron similares en los de los grupos y no fueron identificados factores de riesgo para ansiedad-estado y ansiedad-trazo.

Exames complementares pré-operatórios: análise crítica

BACKGROUND AND OBJECTIVES Preoperative evaluation can benefit from laboratory exams in specific patients. The habit of requesting a set of standardized exams has been questioned. The objective of this review was to analyze recent reports on the subject and compare their results. CONTENTS The results obtained from a systematic revision of the evidence available from 1966 to 1996, from the recommendations of the task force of the American Society of Anesthesiologists, from the systematic revision of evidence from 1997 to 2002, and from the English National Health Service Orientation Guide. CONCLUSIONS Preoperative exams should not be based on standard routines, but on the patients history, physical exam, and type and extent of surgery.JUSTIFICATIVA Y OBJETIVOS: La evaluacion preoperatoria puede beneficiarse de la solicitud de examenes complementarios en determinados pacientes. La practica comun hace algunos anos, de conjuntos estandarizados de examenes solicitados por rutina ha sido cuestionada. El objetivo de esa revision fue el de analizar recientes publicaciones sobre el asunto comparando sus resultados. CONTENIDO: Se analizaron los resultados observados en revision sistematica con las evidencias disponibles entre los anos 1966 y 1996, en recomendaciones del contingente de la Sociedad Norteamericana de Anestesiologos, en actualizacion de la revision sistematica incluyendo evidencias desde 1997 a 2002 y en el Guia de Orientacion del National Health Service de la Inglaterra. CONCLUSIONES: los examenes preoperatorios no deben ser solicitados basados en rutinas, sino orientados por la hoja clinica, por el examen fisico y por el tipo y porte del procedimiento quirurgico.

Difficult intubation in children: applicability of the Mallampati index

BACKGROUND AND OBJECTIVES The concern of facing difficult airways brought the need of developing predictive testing for difficult intubation. Those tests were developed primarily for adult populations. In pediatric patients studies always focus on patients with congenital malformation, polytraumatized, and newborns. The objective of the present study was to determine the applicability of the predictive test used more often in adults, the Mallampati index, in patients 4 to 8 years old, correlating it with the Cormack-Lehane index. METHODS One hundred and eight patients 4 to 8 years of age, ASA I, without any type of congenital malformation, genetic syndromes or cognitive deficits were evaluated. The Mallampati index was applied to patients during the pre-anesthetic evaluation. Evaluation of the Cormack-Lehane index was performed after anesthetic induction. A p<0.05 was considered significant. RESULTS The Mallampati index showed a significant correlation with the Cormack-Lehane index. The sensitivity and specificity of the Mallampati index were 75.8% and 96.2% respectively, but the sensitivity showed a wide confidence interval. CONCLUSIONS The Mallampati index was proven to be applicable in children 4 to 8 years old.

Supraclavicular brachial plexus block: a comparative clinical study between bupivacaine and levobupivacaine

BACKGROUND AND OBJECTIVES Brachial plexus block is used in surgical procedures of the upper limbs. The brachial plexus is a potential territory for absorption of local anesthetics. Studies on bupivacaine isomers have shown reduced cardiovascular toxicity of its levorotatory form (levobupivacaine). However, the anesthetic efficacy (sensorial and motor blockades) of levobupivacaine in neuroaxis blocks has been debated. The objective of this study was to demonstrate the anesthetic efficacy of levobupivacaine in brachial plexus block, using the perivascular subclavian approach, by comparing it to racemic bupivacaine. METHODS Fifty adult patients of both genders, ASA I and II, underwent subclavian perivascular brachial plexus block, with the aid of a peripheral neurostimulator, for orthopedic surgeries of the upper limbs. Patients were randomly divided into two groups: G BUPI - racemic bupivacaine, and G LEVO - levobupivacaine, and they received 30 mL of the 0.5% solution. Sensorial blockade was evaluated by pinprick stimulation from C5 to C8 metameres; and the motor blockade was assessed 1, 2, 5, 10, 15, 20, 25, and 30 minutes after the administration of the local anesthetic or until blockade of fingers, hand, forearm, and arm movements was observed. RESULTS Statistical differences in latency, failure rate, and degree of the motor blockade, and failure of the sensorial blockade between both groups were not observed, but the latency of the sensorial blockade in all metameres analyzed showed statistically significant differences. Adverse events inherent to the administration of local anesthetics were not observed. CONCLUSIONS The anesthetic efficacy of levobupivacaine in brachial plexus block was similar to that of the racemic solution commonly used.

Bloqueio do plexo braquial por via supraclavicular: estudo clínico comparativo entre bupivacaína e levobupivacaína

BACKGROUND AND OBJECTIVES: Brachial plexus block is used in surgical procedures of the upper limbs. The brachial plexus is a potential territory for absorption of local anesthetics. Studies on bupivacaine isomers have shown reduced cardiovascular toxicity of its levorotatory form (levobupivacaine). However, the anesthetic efficacy (sensorial and motor blockades) of levobupivacaine in neuroaxis blocks has been debated. The objective of this study was to demonstrate the anesthetic efficacy of levobupivacaine in brachial plexus block, using the perivascular subclavian approach, by comparing it to racemic bupivacaine. METHODS: Fifty adult patients of both genders, ASA I and II, underwent subclavian perivascular brachial plexus block, with the aid of a peripheral neurostimulator, for orthopedic surgeries of the upper limbs. Patients were randomly divided into two groups: GBUPI - racemic bupivacaine, and GLEVO - levobupivacaine, and they received 30 mL of the 0.5% solution. Sensorial blockade was evaluated by pinprick stimulation from C5 to C8 metameres; and the motor blockade was assessed 1, 2, 5, 10, 15, 20, 25, and 30 minutes after the administration of the local anesthetic or until blockade of fingers, hand, forearm, and arm movements was observed. RESULTS: Statistical differences in latency, failure rate, and degree of the motor blockade, and failure of the sensorial blockade between both groups were not observed, but the latency of the sensorial blockade in all metameres analyzed showed statistically significant differences. Adverse events inherent to the administration of local anesthetics were not observed. CONCLUSIONS: The anesthetic efficacy of levobupivacaine in brachial plexus block was similar to that of the racemic solution commonly used.

Measurement of anxiety and depression in preoperative patients. Comparative study

JUSTIFICATIVA Y OBJETIVOS: Los pacientes que seran sometidos a un procedimiento quirurgico tuvieron ansiedad. La ansiedad y la depresion son los disturbios mas asociados a las enfermedades fisicas. En la Escala Hospitalaria de Ansiedad y Depresion (HADS) no figuran items que podrian estar presentes en enfermedades fisicas y en la ansiedad y en la depresion. El objetivo de este estudio fue medir la frecuencia y el nivel de la ansiedad y de la depresion en pacientes en el preoperatorio y en un grupo control. METODO: Setenta y nueve pacientes internados en el Departamento de Cirugia de la Santa Casa de Sao Paulo y 56 acompanantes respondieron a un cuestionario de datos socio demograficos y la HADS. RESULTADOS: La evaluacion de los sintomas mostro que 35 (44,3%) pacientes y 36 (64,3%) acompanantes fueron considerados con ansiedad (teste exacto de Fisher - p = 0,03) y 21 (26,6%) pacientes y 23 (41,1%) acompanantes fueron considerados con depresion (p = 0,09). En relacion al impacto de las variables socio demograficas sobre la medida de la ansiedad y de la depresion, se observo apenas que los pacientes sin empleo presentaron un nivel mas elevado de ansiedad. CONCLUSIONES: Este estudio confirmo la posibilidad del uso de la escala HADS de ansiedad y depresion en pacientes quirurgicos internados. Tambien nos mostro que la evaluacion de la ansiedad en el periodo preoperatorio debe ser realizada, independientemente de que el paciente presente o no enfermedad clinica y/o quirurgica grave, pues la frecuencia de pacientes con ansiedad es relevante y ellos merecen algun tipo de cuidado diferenciado, como minimo el uso de medicacion ansiolitica antes de la intervencion quirurgica. Fueron encontrados niveles significativamente mayores de ansiedad entre los acompanantes de los pacientes. Esas personas, evaluadas sin que existiese un concomitante problema clinico, posiblemente demostraron estar expuestas a un nivel ostensible de estres, lo que conllevo a un estado de ansiedad mayor que el que tendrian los pacientes que serian sometidos a procedimiento quirurgico.BACKGROUND AND OBJECTIVES Patients scheduled for surgeries experience anxiety. Anxiety and depression are the disorders most commonly associated with organic diseases. The Hospital Anxiety and Depression Scale (HADS) does not include items that could be present in organic diseases and in anxiety and depression. The objective of this study was to measure the frequency and the level of anxiety and depression in preoperative patients and in a control group. METHODS Seventy-nine patients admitted to the Surgical Department of Santa Casa de São Paulo and 56 caretakers answered a questionnaire on socio-demographic data and the HADS. RESULTS The evaluation of the symptoms showed that 35 (44.3%) patients and 36 (64.3%) caretakers had anxiety (Fisher Exact test - p = 0.03) and 21 (26.6%) patients and 23 (41.1%) caretakers had depression (p = 0.09). Regarding the impact of the socio-demographic data on the measurement of anxiety and depression, it was only observed that patients that were unemployed had higher anxiety levels. CONCLUSIONS This study confirmed that the HADS could be used in hospitalized surgical patients. It also showed that patients should be evaluated preoperatively for anxiety and depression, regardless of the presence of severe clinical and/or surgical disorders, because the frequency of patients with anxiety is relevant and they deserve a differentiated approach - at least the administration of tranquilizers before surgery. Caretakers presented significantly higher levels of anxiety. Those people, evaluated in the absence of concomitant clinical problems, probably demonstrated to be exposed to a considerable level of stress, resulting in a higher anxiety state than the patients scheduled for surgeries.JUSTIFICATIVA E OBJETIVOS: Os pacientes que vao ser submetidos a um procedimento cirurgico experimentam ansiedade. A ansiedade e a depressao sao os disturbios mais associados as doencas fisicas. Na Escala Hospitalar de Ansiedade e Depressao (HADS) nao figuram itens que poderiam estar presentes em doencas fisicas e na ansiedade e na depressao. O objetivo deste estudo foi medir a frequencia e o nivel da ansiedade e da depressao em pacientes no pre-operatorio e em um grupo-controle. METODO: Setenta e nove pacientes internados no Departamento de Cirurgia da Santa Casa de Sao Paulo e 56 acompanhantes responderam a um questionario de dados sociodemograficos e a HADS. RESULTADOS: A avaliacao dos sintomas mostrou que 35 (44,3%) pacientes e 36 (64,3%) acompanhantes foram considerados com ansiedade (teste Exato de Fisher - p = 0,03) e 21 (26,6%) pacientes e 23 (41,1%) acompanhantes foram considerados com depressao (p = 0,09). Com relacao ao impacto das variaveis sociodemograficas sobre a medida da ansiedade e da depressao, foi observado apenas que os pacientes desempregados apresentaram nivel mais elevado de ansiedade. CONCLUSOES: Este estudo confirmou a possibilidade do uso da escala HADS de ansiedade e depressao em pacientes cirurgicos internados. Ele mostrou tambem que a avaliacao da ansiedade no periodo pre-operatorio deve ser realizada, independentemente de o paciente apresentar ou nao doenca clinica e/ou cirurgica grave, pois a frequencia de pacientes com ansiedade e relevante e estes merecem algum tipo de cuidado diferenciado no minimo o uso de medicacao ansiolitica antes da intervencao cirurgica. Foram encontrados niveis muito maiores de ansiedade entre os acompanhantes dos pacientes. Essas pessoas, avaliadas sem que houvesse um concomitante problema clinico, possivelmente demonstraram estar expostas a um consideravel nivel de estresse, o que resultou em estado ansioso maior do que os pacientes que seriam submetidos a procedimento cirurgico.

Preoperative exams: a critical analysis

BACKGROUND AND OBJECTIVES Preoperative evaluation can benefit from laboratory exams in specific patients. The habit of requesting a set of standardized exams has been questioned. The objective of this review was to analyze recent reports on the subject and compare their results. CONTENTS The results obtained from a systematic revision of the evidence available from 1966 to 1996, from the recommendations of the task force of the American Society of Anesthesiologists, from the systematic revision of evidence from 1997 to 2002, and from the English National Health Service Orientation Guide. CONCLUSIONS Preoperative exams should not be based on standard routines, but on the patients history, physical exam, and type and extent of surgery.JUSTIFICATIVA Y OBJETIVOS: La evaluacion preoperatoria puede beneficiarse de la solicitud de examenes complementarios en determinados pacientes. La practica comun hace algunos anos, de conjuntos estandarizados de examenes solicitados por rutina ha sido cuestionada. El objetivo de esa revision fue el de analizar recientes publicaciones sobre el asunto comparando sus resultados. CONTENIDO: Se analizaron los resultados observados en revision sistematica con las evidencias disponibles entre los anos 1966 y 1996, en recomendaciones del contingente de la Sociedad Norteamericana de Anestesiologos, en actualizacion de la revision sistematica incluyendo evidencias desde 1997 a 2002 y en el Guia de Orientacion del National Health Service de la Inglaterra. CONCLUSIONES: los examenes preoperatorios no deben ser solicitados basados en rutinas, sino orientados por la hoja clinica, por el examen fisico y por el tipo y porte del procedimiento quirurgico.